Cochrane for Clinicians

Putting Evidence into Practice

Spinal Manipulative Therapy for Low Back Pain

KATHERINE MARGO, M.D., University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available online at http://www.cochrane.org/cochrane/revabstr/AB000447.htm.

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Katherine Margo, M.D., presents a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.

Clinical Scenario

A 42-year-old woman presents with low back pain that started after she had moved furniture a week earlier. She wants pain relief as quickly as possible and asks if she should go to a chiropractor.

Clinical Question

Should we recommend spinal manipulation as a treatment for low back pain?

Evidence-Based Answer

In the short term, manipulative therapy is as effective for acute or chronic low back pain as other treatments such as analgesics, physical therapy, exercises, back school, and routine care from a primary care physician. Radiation of pain, type of manipulation, and use of multiple modalities do not alter these results.

Cochrane Abstract

Background. Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain. Objectives. To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and incorporating data from recent high-quality randomized controlled trials (RCTs) into the analysis. Search Strategy. The authors1 searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL through January 2000, using the Back Group search strategy. References from previous systematic reviews also were screened. Selection Criteria. RCTs that evaluated spinal manipulative therapy for patients with low back pain were selected if they included at least one day of follow-up and at least one clinically relevant outcome measure. Data Collection and Analysis. Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (e.g., traction, corset, bed rest, home care, topical gel, no treatment, diathermy, minimal massage). Primary Results. A total of 39 RCTs were identified. Meta-regression models were developed for acute and chronic pain, short-term and long-term pain, and function. In patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10 mm difference on a 100 mm visual analog scale [95 percent confidence interval, 2 to 17 mm]) or therapies judged to be ineffective or harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results in patients with chronic low back pain were similar. Radiation of pain, study quality, profession of the manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. Reviewers' Conclusions. There is no evidence that spinal manipulative therapy is superior to other standard treatments in patients with acute or chronic low back pain.

These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the original reviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minor editing changes have been made to the text (www.cochrane.org).

Practice Pointers

There are many options for treatment of acute and chronic low back pain: physical therapy, exercise, analgesics, muscle relaxants, acupuncture, manipulation, exercise, and massage. Most patients get better within six weeks regardless of treatment. The Agency for Health Care Policy and Research guidelines of 1994,2 as well as other, more recent national guidelines, recommend manipulation for acute low back pain without radiculopathy, and some guidelines recommend it for chronic low back pain. This review, which looked at clinical trials through January 2000, evaluated the role of spinal manipulative therapy.

The evidence in this review shows that manipulation is as effective as analgesics, physical therapy, exercise, and usual care from a family physician. Manipulation is better than sham therapy and several methods that have been shown to be ineffective or harmful, such as traction, corsets, bed rest, diathermy, and no therapy. The studies included in the review examined all types of patients with back pain, including those with radicular pain. Many of the studies examined multiple therapies used concurrently, which made the analysis more difficult. There was no evidence that manipulation was better for any subgroup of low back pain.

The Randomized Osteopathic Manipulation Study,3 which was not part of this review, examined osteopathic manipulation and found short-term improvement at two and six months compared with usual care. Another recent study4 of osteopathic treatment for chronic pain found that therapy was as effective as sham treatment. This raises the question of whether treatment causes a placebo effect, perhaps because of the extra time spent with patients. A recent review5 compared acupuncture and massage with manipulation. There was some initial evidence that massage therapy is effective and may reduce the cost of care. The anticipated results of the United Kingdom Back Pain, Exercise, and Manipulation trial6 comparing exercise, manipulation, or both with standard primary care in 1,350 patients for one year should provide additional data to help answer this question.

REFERENCES

The Author

Katherine Margo, M.D., is predoctoral director and assistant professor of family and community medicine at the University of Pennsylvania School of Medicine, Philadelphia, where she also serves as associate residency director. Dr. Margo received her medical degree from State University of New York Upstate Medical University, Syracuse, and completed a family medicine residency at St. Joseph's Hospital in Syracuse.

Address correspondence to Katherine Margo, M.D., Department of Family Practice and Community Medicine, University of Pennsylvania School of Medicine, 2 Gates/3400 Spruce St., Philadelphia, PA 19104 (e-mail: margok@uphs.upenn.edu). Reprints are not available from the author.

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Cochrane Briefs

Efficacy of Antioxidants in GI Cancer Prevention

Clinical Question

Does supplementation with antioxidant vitamins prevent gastrointestinal (GI) cancer?

Evidence-Based Answer

There is no evidence that supplementation with beta carotene or vitamins A, C, or E prevents GI cancer. Data for selenium is inconsistent and based on poor-quality studies, and supplementation with this mineral should not be recommended routinely. Most importantly, combinations of antioxidant vitamins appear slightly to increase overall mortality rates.

Practice Pointers

Until recently, vitamin E and other antioxidants had been considered safe and possibly effective in the prevention of heart disease and various malignancies. However, a recent meta-analysis1 of studies of vitamin E supplementation for prevention of heart disease found no benefit and even a possible increase in risk at dosages above
400 IU per day. In the current Cochrane review, Bjelakovic and colleagues identified 14 randomized controlled trials of more than 170,000 patients that compared beta carotene, selenium, and vitamins A, C, and E with placebo for prevention of GI cancer.

No single antioxidant or combination of antioxidants significantly reduced the incidence of esophageal, gastric, colorectal, pancreatic, or hepatic cancer. When the results of all antioxidants and antioxidant combinations for a particular cancer were integrated, there was no effect on the incidence of that cancer. There was a trend in favor of selenium for prevention of esophageal, colorectal, and hepatocellular cancer, but it was not statistically significant, and the studies were of limited quality. Most importantly, when the results for all studies were combined using one statistical approach, overall mortality was increased in patients taking antioxidants (relative risk [RR], 1.06; 95 percent confidence interval [CI], 1.02 to 1.10). However, only a trend was noted when a more conservative approach was used (RR, 1.06; 95 percent CI, 0.98 to 1.15). When the selenium trials were excluded, both analyses showed a statistically significant increase in mortality, which was particularly strong in patients taking beta carotene and vitamin A (RR, 1.29; 95 percent CI, 1.14 to 1.45) or beta carotene and vitamin E (RR, 1.10; 95 percent CI, 1.01 to 1.20).

MARK H. EBELL, M.D., M.S.

Bjelakovic G, et al. Antioxidant supplements for preventing gastrointestinal cancers. Cochrane Database Syst Rev 2004;(4):CD004183.

REFERENCE

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Delaying Antibiotics for Respiratory Infections

Clinical Question

What effect does delayed prescribing of antibiotics have on the clinical course of respiratory infections and the likelihood of complications?

Evidence-Based Answer

Delayed prescribing appears to be a reasonable and safe option in patients with cough and in those who do not appear very ill, but it cannot be recommended for children with sore throat unless streptococcal pharyngitis has been ruled out. Delayed prescribing of antibiotics results in a small increase in symptoms in some groups of patients at day 3. However, this risk must be balanced against the benefits of fewer antibiotic side effects, less antibiotic resistance, and lower cost.

Practice Pointers

Delayed prescribing is one strategy for reducing antibiotic use for common respiratory tract infections (RTIs). Most of these infections are viral and do not benefit from the use of antibiotics. Delayed prescribing means giving patients a prescription but suggesting that they not fill it unless they begin to feel worse or develop specific symptoms, or requiring that patients call the practice or pick up a prescription at a later date if their symptoms persist or worsen. A previous systematic review1 showed that delayed antibiotic prescribing for RTIs reduces by one half the number of patients who take an antibiotic. In this review, Spurling and colleagues identified seven good-quality randomized controlled trials that assigned patients to immediate or delayed antibiotics and followed them prospectively to determine their clinical outcomes.

The studies included patients with sore throat, common cold, otitis media, and cough. The results were mixed. In three studies of unselected children with sore throat (many of whom likely had streptococcal infection), patients in the delayed antibiotic group were more likely to have a fever on day 3. Findings were similar for pain and malaise: some studies found a benefit with immediate antibiotics, and some did not. Studies showing a benefit tended to enroll sicker patients.

Delayed antibiotic prescribing often is used in adults with cough; only one study considered this group, and it found no difference in outcomes. There were no consistent differences in reconsultation rates or complications between patients who received delayed treatment and those who received treatment immediately.

MARK H. EBELL, M.D., M.S.

Spurling G, et al. Delayed antibiotics for symptoms and complications of respiratory infections. Cochrane Database Syst Rev 2004;(4):CD004417.

REFERENCE

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